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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603481
Report Date: 01/31/2025
Date Signed: 01/31/2025 06:56:41 PM

Document Has Been Signed on 01/31/2025 06:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MARYAM ARFFACILITY NUMBER:
374603481
ADMINISTRATOR/
DIRECTOR:		LEEDA DOSTFACILITY TYPE:
735
ADDRESS:9319 NORTHVIEW TERRACETELEPHONE:
(858) 348-7247
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY: 6CENSUS: 4DATE:
01/31/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Caregiver Fawzia ShalabiTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Correia conducted an unannounced case management visit at the facility. LPA gained access to the facility, identified herself, and met with Caregiver Shalabi to whom was explained the purpose of the visit.

During today's visit LPA conducted a staff interview and conducted a client record review.

Today's visit was in response to a Death Report received on January 30, 2025, by Community Care Licensing (CCL) regarding Client 1 (C1). No deficiencies were cited during today's visit.(See LIC 811 for confidential name).

An exit interview was conducted with Caregiver Shalabi and a copy of this report and Licensee/Appeal Rights (LIC9058 01/16) will be provided at the conclusion of the visit. Signature below confirms receipt of the reports.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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